Texas Certificate Of Death Form
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1STATE OF TEXAS
CERTIFICATE OF DEATH
STATE FILE NUMBER
1.
LEGAL NAME OF DECEASED (Include AKA's if any)
(First,
Middle,
Last)
(Maiden)
2. DATE OF DEATH
-ACTUAL
OR PRESUMED
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3. SEX
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6. BIRTHPLACE (City & State or Foreign Country)
4.
DATE
OF BIRTH
5. AGE-Last Birthday
IF UNDER 1 YR
IF UNDER 1 DAY
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(Years)
DAYS
MO
HOURS
MIN
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7.
SOCIAL
SECURITY NUMBER
9.
SURVIVING SPOUSE (If
wife,
give name prior to first
marriage)
8. MARITAL STATUS AT TIME OF DEATH
Married
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D
D
D
D
Widowed
Divorced
Never Married
Unknown
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10a. RESIDENCE STREET ADDRESS
10b. APT NO
1
Oc. CITY OR TOWN
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10d. COUNTY
10e.
STATE
10f. ZIP CODE
10g. INSIDE CITY LIMITS?
Cl)
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Yes
No
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11. FATHER'S
NAME
12.
MOTHER'S NAME PRIOR TO FIRST MARRIAGE
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Cl)
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13. PLACE OF DEATH
(CHECK
ONLY
ONE)
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IF DEATH OCCURRED IN A HOSPITAL
IF DEATH OCCURRED
SOMEWHERE
OTHER THAN A
HOSPITAL:
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D
D
D
D
D
D
Inpatient
ER/Outpatient
DOA
Hospice Facility
Nursing Home
Decedent's Home
Other (Specify)
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14.
COUNTY OF DEATH
15.
CITY/TOWN,
ZIP (If outside city
limits,
give precinct
no)
16. FACILITY NAME (If not
institution,
give street address)
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17.
INFORMANT'S NAME & RELATIONSHIP TO DECEASED
18. MAILING ADDRESS OF INFORMANT
(Street
and
Number,
City,
State,
Zip Code)
1-
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